Tobacco Use and Spine Surgery

The adverse effects of tobacco and marijuana use on the spine before, during, and after surgery are undeniable. Patients must do everything in their power to refrain completely in the perioperative period, especially if a fusion is planned. You and your surgical team need to work together to accomplish abstinence. Potential complications are discussed in detail.

Suppose you and your surgeon have decided to proceed with an anterior cervical fusion for a herniated disc producing spinal cord compression. Your surgeon tells you that you must quit smoking before surgery. You cut back to 10 cigarettes a day and go ahead with the surgery. No problem – right? WRONG! Instead you decide to chew tobacco. No problem—right? WRONG! Ok, so now you have switched to nicotine patches and gum. STILL NOT OK!

Successful outcomes after attempted cervical fusion surgery depend on new bone formation and achieving a solid bony fusion. Cigarette smoke has been shown to contain over 4000 different chemical constituents, including carbon monoxide (CO). CO has been unequivocally shown to increase the risk of poor tissue oxygen levels, leading to impaired bone formation as well as impaired wound healing with risk of infection. In fact, CO is recognized as a “bone poison” with regard to new bone formation. This represents a critical risk of poor outcome with chronic pain due to a failed cervical fusion (pseudoarthrosis – see the related article on This is especially problematic as we age, as bone loss for both men and women begins around age 40. In addition, in women, cigarette smoke lowers estrogen levels, leading to osteoporosis/ osteopenia and overall poor bone quality for healing (including other problems like increased risk of vertebral compression fractures). Nicotine leads to release of catecholamines, causing blood vessel constriction and further impairment to normal blood flow. Without adequate blood flow, bone forming cells (osteoblasts and osteocytes) cannot adequately perform their functions and form new bone. In addition, tobacco-borne chemicals have been shown to accelerate the normal degeneration of spinal discs, ligaments, and joints, accelerating the rate of osteoarthritis and leading to chronic neck and back pain. Second hand smoke is as bad as primary smoking.

Marijuana is just as deleterious. Among its 500 known deleterious chemical constituents is the active compound tetrahydrocannabinol (THC – one of over 100 cannabinoids). THC has been proven to be a potent immunosuppressant, inhibiting the body’s ability to fight infection and eliminate “precancerous” cells.

Postoperative complications attributed to tobacco use include:

  1. Higher risks of pneumonia and symptomatic heart disease.
  2. Higher rates of post-operative infection and fluid collections (seromas).
  3. Higher rates of chronic post-op pain associated with incomplete fusion, especially in patients with multilevel surgery, whether treated with anterior or posterior approaches.
  4. Delay in wound healing.
  5. Higher rate of post-operative blood clots (deep venous thromboses).
  6. Higher rates or reoperation.
  7. Longer hospital stays with higher overall costs. In fact, the state of Oregon will no longer provide coverage for Medicaid patients to under spinal fusion surgery if the patient is still a smoker.
  8. Although improved after surgical intervention, when asked about their outcomes after spine surgery , smokers in general report more symptoms and worse outcomes at 12 months, with a distinctly lower quality of life.
  9. Although bone morphogenic protein (BMP-2) has been shown to help with bone formation in chronic smokers, it has its own inherent set of risks and complications.

The optimal time period between quitting all forms of tobacco and marijuana use (including nicotine-containing gum, lozenges, sprays, vaping, and patches) remains unclear. Studies suggest that a period of abstinence of 6 months is optimal but 4-6 weeks seems more practical. Patients must also refrain from tobacco use for at least 3 months or longer after surgery to allow formation of adequate bone. Complete abstinence may require a multi-modality approach, including attendance at a smoking cessation clinic, where modalities such as acupuncture, counseling, medications such as varenicline and mild antidepressants, etc. have been shown to be useful. All tobacco users in our practice undergo a pre-operative blood draw for cotinine to make certain nicotine levels are sufficiently low to proceed with fusion surgery with acceptable risk.

In summary, the widespread adverse effects of tobacco use prior to cervical fusion surgery are not worth the risk of a poor outcome. This article is not meant to shame tobacco users, by any means. If you are a smoker, your job before surgery is to quit completely, by any means necessary. If you and your significant other smoke, now is the best time for you both to quit. In addition do not fear communicating with your physician that you are still smoking or having trouble with quitting. The best surgical outcomes result from every one participating in the healing process, and we as health care professionals are always there to help. Feel free to call us with any questions at +1-(855)-854-9274

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